Welcome to our practice! Our entire staff appreciates the opportunity you have given us to provide you with a pleasant experience while you are here.

Transcription

1 Welcome to our practice! Our entire staff appreciates the opportunity you have given us to provide you with a pleasant experience while you are here. You have been given several forms to read and complete. The purpose of these forms is to assist us in providing you with the high level of care that you are looking for. We understand that you may have completed similar forms at your dentist s or physician s office, however we do ask that you take your time to carefully read and accurately fill out these forms. If you have any questions, please do not hesitate to ask for assistance. Sincerely, Drs. Gregory Lehman & Michael Menis

2 Patient: (Dr., Master, Miss, Mr., Mrs., Ms. ) Lehman & Menis Oral & Maxillofacial Surgery First MI Last Nickname: Apt # City State Zip Phone H ( ) Phone W ( ) Ext. Cell/Pager # ( ) DOB: Sex: Male Female SS #: Employer Address Have any family members, relatives or friends been treated in our office? Y N If yes, please name: Name of Person/Doctor who referred you to our office: FIRST NAME LAST NAME Physician Information Do you have a Dentist? Y N Name of Dentist City Phone: ( ) FIRST NAME LAST NAME Do you have a Physician? Y N Name of Physician City Phone: ( ) FIRST NAME LAST NAME Guarantor (Person financially responsible for patient) Patient relation to Guarantor: Self Spouse Child Parent Other If other than self, please complete: Guarantor (Dr., Miss, Mr., Mrs., Ms. ) First initial last Please indicate if Apt # we may call you City State Zip at work: DOB: SS # Phone H ( ) Employer Address Yes No Phone W ( ) Cell/Pager# ( ) Insured Party Information Primary Dental Insured Party Info (Card Holder) Primary Medical Insured Party Info (Card Holder) Secondary Dental Insured Party Info (Card Holder) Secondary Medical Insured Party Info (Card Holder) Notice of Privacy Practices Acknowledgement I,, herby acknowledge that I have received a copy of this practice s Notice of Privacy Practices. I have been given the opportunity to ask any questions I may have regarding this Notice. Signature

3 Lehman & Menis Oral & Maxillofacial Surgery Health History Questionnaire Today s : Name: of Birth: Age: Reason for today s visit: Height: Weight: Medical Doctor: Phone: ( ) of last visit: Have you ever had surgery or been hospitalized? Yes No If yes, please explain: Have you ever had or been treated for any medical problems or illness? Yes No If yes, please explain: Have you had, or do you currently have any of the following? PLEASE CIRCLE ALL RESPONSE Damaged or prosthetic heart valve Mitral valve prolapse or Heart Murmur High blood pressure Chest pain, angina Heart attack Blood clot in veins or lung Irregular heart beat/arrhythmia Heart surgery, Angioplasty, Pacemaker Congestive heart failure Stroke or TIA Asthma Emphysema or COPD Blood disorder or Anemia Blood transfusion Excessive bleeding after cut or surgery Thrombocytopenia or Hemophilia Hepatitis or liver disease Fainting spells or syncope Convulsions, epilepsy, seizures Thyroid disorder ADD/ADHD Depression Anxiety Anxiety Attacks Adverse reaction to anesthesia Diabetes If yes, do you take insulin Lupus Kidney problems or Dialysis GERD, Reflux, Ulcer Cancer Chemotherapy Radiation treatment If yes, body area Eye disease/glaucoma Sleep apnea. If yes do you use a CPAP machine? Sinus problems Difficulty breathing through nose Artificial joint (knee, hip, other) Rheumatoid Arthritis Numbness/tingling in face Ear pain/jaw joint pain Pop or click in jaw joint Jaw locking open or closed History of drug or alcohol abuse Malignant hyperthermia MEDICATIONS Are you currently taking any prescription medication?.. If yes, please list medication name(s) and dosage(s): Are you currently taking any non-prescribed over the counter or herbal medications.. If yes, please list medication name(s) and dosage(s): PLEASE CONTINUE ON OTHER SIDE

4 Have you ever taken bisphosphonate medications for the treatment of osteoporosis/osteopenia or bone cancer such as, Zometa (Zoledronic Acid), Aredia (Pamidronate), Fosamax (Alendronate), Actonel (Risedronate), Boniva (Ibandronate Sodium) or Reclast (Zoledronic Acid), Xgeva or Prolia (denosumab) injections If yes, are you currently taking the medication If yes, please list medication: For how long If you are no longer taking, when did you stop Has your physician ever told you that you are required to take antibiotics for a heart murmur, heart valve problem, bone plates, or artificial joint prior to dental procedures? Do you take any of the following blood thinners: Plavix... Coumadin... Asprin.. Xarelto. Effient.. Levenox.. Pradaxa Brilinta..... Have you taken any steroid medication (e.g. prednisone) during the last two years?... ALLERGIES Are you allergic or ever had a reaction to: Local anesthetic, Novocain... Penicillin/Amoxicillin... Erythromycin/Biaxin... Sulfa/Septra/Bactrim... Cephalosporins (e.g.ceclor, Keflex)... Clindamycin, Cleocin... Levaquin/Cipro... Iodine or IV contrast... Egg or Egg Products... Valium or other sedatives... Codeine, Hydrocodone, Vicodin... Fentanyl, Morphine... Please describe specific allergic reaction to any yes answer above: Asprin.. Ibuprofen or other anti-inflammatory drugs... Latex examination gloves. Allergies to other drug or medication?... Please list: Allergies other than medication. Please list: Do you currently smoke?. Have you ever smoked?... packs/day Do you use cocaine or any other drugs or substances? Have you ever been treated for substance abuse and/or drug addiction?...yes No Do you have any other information you think the doctor should know about or that you would like to discuss in private with the doctor? WOMEN ONLY Is there a possibility of pregnancy? If yes, estimated delivery date: *Surgery and/or anesthesia during early pregnancy can potentially harm a developing baby. Are you nursing? Are you taking birth control pills? *Antibiotics (such as penicillin) may alter the effectiveness of birth control pills. I certify that I have read and understand the questions above, and that the information that I have provided is correct to the best of my knowledge. I understand that it is important for my doctor to be familiar with my complete medical history. I authorize Dr. Gregory A. Lehman, Dr. Michael A. Menis and designated staff to perform an examination, for the purpose of diagnosis and treatment planning. Furthermore, I authorize the taking of x-rays and photographs required of this examination. In addition, if medically necessary, I authorize the release of any information acquired in the course of my examination and treatment. Patient s Signature Signature of Legal Guardian/Relationship (if patient under 18) Doctor s Signature

5 OFFICE INSURANCE POLICY Patient Name: We welcome and encourage discussion of services and fees prior to treatment. Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor, but is usually not designed to pay the entire fee. Insurance coverage is variable between insurance companies, and even between individual policies within the same company. Benefits can also vary between in-network and out of network providers. If you have concerns that or practice is not in your insurance network, we strongly encourage you call your insurance company and verify. There are deductibles that must be fulfilled prior to payment of benefits, and many plans have annual maximum allowances that once exceeded, do not provide additional benefits. Insurance companies use the terms allowable, U & C (usual and customary) and UCR (usual, customary and reasonable) when determining the portion of fees that they are responsible for paying. These fees are determined and agreed upon by the insurance company and your employer, and are often lower than the actual fees charged. Because the insurance contract is between the insured and the insurance company, it is ultimately your responsibility to pay the portion of the bill not paid by your insurance company. If you would like to know what your approximate financial responsibility will be for services to be rendered, we will gladly send a pre-estimate to your insurance company for them to review. This process does require a consultation and x-ray prior to the procedure and can take four weeks or longer to receive a reply from your insurance company. If you would rather proceed with treatment without a pre-estimate, we require payment of the portion estimated not to be covered by your insurance plan at the time the service is rendered. Actual eligibility, benefits and coverage can only be determined by your insurance plan upon receipt and processing of the claim once services are provided. When the insurance payment is received, any amount in excess of your account balance will promptly be refunded to you. Conversely, any balance remaining after insurance pays will be your responsibility. Any balance remaining after all insurance pays will be due immediately. Partial payments will not be acceptable. For any reason, if your insurance company has not paid your claim within 90 days, you will be responsible for the remaining balance. Our office will gladly continue to work with your insurance, and provide any information required to process the claim. Any balances not paid within 90 days will be subject to 1½% monthly interest charge. In addition, should the account be referred to a collection agency, you will be liable for all attorney fees. My signature authorizes the release of information requested by the insurance company which is necessary to process my claim. I hereby assign payment of benefits otherwise payable to me to Lehman & Menis Oral & Maxillofacial Surgery, P.C.. I understand that I am financially responsible for all charges not covered by my insurance company. If you have any questions, we will be happy to assist you. Name of Insured/Guarantor: (Please Print) Signature of Insured/Guarantor: : 3/15/17